Individual
MICHAEL J DI DOMENICO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PSYD
Contact information
Practice address
707 SKOKIE BLVD STE 600, NORTHBROOK, IL 60062-2841
(630) 632-0746
(847) 272-8221
Mailing address
PO BOX 472, NORTHBROOK, IL 60065-0472
(847) 504-4060
(847) 919-8399
Taxonomy
Speciality
Code
Description
License number
State
103G00000X
Clinical Neuropsychologist
Primary
071005762
IL
103TC0700X
Clinical Psychologist
071005762
IL
103TC0700X
Clinical Psychologist
071055762
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1623280
BLUE CROSS BLUE SHIELD
IL
Enumeration date
05/12/2006
Last updated
07/25/2022
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